An Agenda to Strengthen the Developmental Disabilities Direct Support Professional Workforce in Illinois

Quality Support 2005 An Agenda to Strengthen the Developmental Disabilities Direct Support Professional Workforce in Illinois Illinois Direct Support Professional Workforce Initiative:

Quality Support 2005

An Agenda to Strengthen the Developmental

Disabilities Direct Support Professional Workforce in Illinois

Illinois Direct Support Professional Workforce Initiative: A partnership of the Institute on Community Integration at the University of Minnesota, Institute on Disability and Human Development at the University of Illinois at Chicago, and the Human Services Research Institute.

Supported by the Illinois Council on Developmental Disabilities.

Values and Vision

The Illinois Direct Support Professional Workforce Initiative, a project supported by the IllinoisCouncil on Developmental Disabilities, brings together stakeholders to address the scarcity

of qualified people available to provide direct support for people with developmental

disabilities1 living in communities throughout Illinois The initiative focuses specifically on strengthening the direct support workforce supporting people with developmental

disabilities (including people who have intellectual disabilities), but its work and outcomes are applicable to the broader group of direct support practitioners serving people in Illinois with other types of disabilities

The work of the initiative has been inclusive and collaborative to assure that all

stakeholders are part of the solution The initiative’s Steering and Advisory Committee (SAC)includes people with developmental disabilities and their families, advocacy organizations, providers and provider associations, Direct Support Professionals (DSPs), workforce

development experts, labor representatives, governmental agencies, and academic

1 The Administration on Developmental Disabilities defines developmental disabilities as

“physical or mental impairments that begin before age 22, and alter or substantially inhibit aperson’s capacity to do at least three of the following: take care of themselves (dress, bathe,eat, and other daily tasks); speak and be understood clearly; learn; walk/ move around; make decisions; live on their own; earn and manage an income.”

professionals (see Appendix A for a complete listing) This committee has held extensive discussions about the dire conditions that make it very difficult for families, people with disabilities and community service agencies to find and retain quality people in direct

support roles They also reviewed effective recruitment, retention, and development

practices with potential for strengthening the direct support workforce These efforts served

to build consensus on directions to take in Illinois in the next five years to strengthen

community support through a stronger workforce These directions are charted in this plan DSPs are vital to the well-being of many people with developmental disabilities The current problems in Illinois with finding, training, and retaining competent direct support staff are having a profound effect on the day-to-day health, safety, and well-being of people and families who rely on direct support, as well as their ability to reach longer term goals of self-determination, full inclusion, employment and civic participation Immediate and

strategic steps must be taken to reverse these conditions and work toward a more positive future expressed in the vision statement created by the Steering and Advisory Committee to guide their work —

People with developmental disabilities, and their families and support networks, have trained, valued, and creative Direct Support Professionals (DSPs) to assist them in living quality lives and fully participating in their communities

To achieve this vision it is necessary to strengthen the direct support workforce by

encouraging people to choose and sustain careers focused on supporting and empowering people with developmental disabilities This plan offers a comprehensive agenda for fulfillingthis vision

Purpose of this Plan

The purposes of this workforce development plan are to —

• Provide essential information about the high turnover, inadequate wages, lack of access tobenefits, high vacancy rates and the growing shortage of DSPs in Illinois;

• Create a call to action from important stakeholders to ensure solutions are created and realized; and,

• Outline an agenda of short term and longer term workforce development solutions to assure the availability of high-quality community supports for those who need it

This plan is based on research, dialogue and strategic planning undertaken by the SAC with the support of the Illinois Council on Developmental Disabilities In preparing this plan, Illinois joins the ranks of a small but progressive group of states that are confronting current direct support workforce problems to build a more sustainable and positive future for people with developmental disabilities

The recommendations in this plan model current strategies known to improve workforce conditions They include a pool of interventions ranging from finding and welcoming new employees to improving organizational management practices, strengthening training and education, and expanding the view of direct support from that of a low skilled job to a

professional role that is part of a long term human services career involving continual

professional development

Who are Direct Support Professionals?

Direct Support Professionals (DSPs) play a critical role in the lives of people with

developmental disabilities and their families DSPs assist people with disabilities in activities

of daily living, social activities, personal contacts, coordination of health care, community interactions, and more The assistance they provide depends upon the situation of each person with a wide range of possible activities such as help in maintaining a home, meeting friends, finding work, providing transportation, making important decisions, taking

medications, learning new skills, paying bills, getting a job, and physical assistance DSPs also facilitate connections to the people, resources and experiences necessary for families and individuals to live fully and safely in Illinois’ neighborhoods and communities The

quality of support individuals with disabilities receive from DSPs has a profound influence on their daily lives

Different terms and titles are often used for the people in this role, but the SAC has

decided to use the term Direct Support Professional (DSP) as a way to emphasize the

importance of the job as well as our vision for increasing the professional status of the role People with disabilities say they want the following from DSPs —

 Treat us like other people,

 Encourage us to do things outside our homes,

 Assist us in locating accessible transportation and in learning how to use it,

 Provide programs that offer choices,

 Involve us in decisions that affect us and let us take responsibility for those decisions,

 Encourage us to speak for ourselves,

 View us as valuable competent people, and

 Treat us with respect and dignity and encourage personal choice and independence

As these statements suggest, a competent direct support workforce contributes more thansupport with activities of daily living Consistent, high-quality support can help individuals with disabilities to achieve individual growth, self-determination, and greater levels of

independence To achieve these critical outcomes, DSPs must be well trained in

competencies such as community networking, communication, and facilitating valued and

empowered roles for the people they support DSPs, however, are often unable to fulfill these complex duties effectively because the current system does not provide sufficient professional development to master these skills.

DSPs are employed by approximately 413 organizations funded by DHS Some are also employed as independent practitioners by people with disabilities who direct their own supports A small yet growing percentage of these DSPs are represented by two labor unions

in Illinois including SEIU and AFSCME

Current Conditions

In Illinois, as in the rest of the nation, our community support system faces high direct support turnover and vacancy rates Inadequate wages and benefits, lack of career and educational ladders, and societal devaluation of helping professions take their toll on this vital workforce endangering those who rely on this support

With these conditions, people with developmental disabilities and their families worry if there will be sufficient support to meet their needs It is impossible to focus on larger life goals and dreams for full inclusion and empowerment when engaged in a daily struggle to find the support essential to meet basic health, safety and daily care needs

Status of Recruitment and Retention

The current consensus among leaders of developmental disabilities systems is that the difficulty in recruiting and retaining a quality workforce leads to a destabilized workforce anderodes the quality of support rendered Nationally, vacancy rates have increased and high turnover rates have continued over the past decade This is partly due to the expansion of service-related jobs created by the robust post-industrial economy, coupled with a national workforce that is not large enough to meet the demand for new jobs

The number of DSPs needed to provide supports to people with developmental disabilities

is expected to grow 37% between 2003 and 2020 or by 323,000 (FTE’s) nationally (Lakin, Hewitt, & Larson, 2005) This number does not include the number of DSPs we would need

to hire to replace those who leave Nationally, based on averages, we would need to hire 437,047 (FTE’s) each year to replace DSPs who leave their jobs On top of keeping pace with turnover, we would need to hire an additional 19,000 (FTE’s) to cover the projected annual growth of direct support jobs between now and 2020 (Lakin, Hewitt & Larson, 2005) Not only is it critical that we keep existing DSPs, but to meet the growing demands we must attract additional, quality DSPs These concerns are echoed in Illinois where the turnover rate for DSP positions in 102 community residential providers averaged 43% in 1997 (Rubin, Park & Braddock, 1998) More than 60% of those who moved on left within the first 12

months after being hired (Rubin, Park & Braddock, 1998) The 2005 Illinois Association of Rehabilitation Facilities Salary Survey of 49 organizations estimated annual turnover rates

for 2004 for all staff positions (including DSPs, supervisors, administrators and other staff) in

DD and Behavioral Health settings was 33% A 2005 study of DD providers reported that 24% of all positions (including DSPs, professionals, administrators and other positions) in vocational and residential community developmental disability settings had been filled at least once in the last 12 months (Powers, Powers, & Merriman, 2005)

These challenges also apply to the organizations selected to participate in this project Table 1 describes the workforce characteristics for the 18 community-based organizations serving people with developmental disabilities that are participating in the Illinois Direct Support Professional Workforce Initiative (See Appendix B for similar information about Illinois state operated developmental centers) The turnover rate for DSPs in these

vocational, residential and in-home support settings was 36.3% At the time the project started 1 out of every 10 DSP positions was unfilled Equally concerning, the turnover rate for FLSs in participating organizations was 16.6%, and 1 in every 20 Frontline Supervisor (FLS) positions was unfilled Advertising costs averaged $94.61 per year per direct support position, and organizations spent 2.7% of their annual budget paying overtime costs

Administrators in the participating organizations identified as their top workforce concerns: finding qualified people to hire, DSP turnover, DSP wages and benefits, staffing schedules and staffing patterns, and training for FLSs (See Appendix B)

Table 1 2004 Baseline Workforce Characteristics for Participating Organizations

Organizational Characteristics

Number of people with developmental disabilities supported 10,477

Number of sites owned and operated by organizations 329

% of people who left within 6 months of hire 35.9%

Estimated annual advertising costs per current DSP $94.61

Estimated annual average number of hours of overtime per current 142.0

Percent of budget spent on overtime in December 2004 2.7%

Discussions with the employer partners in the Illinois Direct Support Professional

Workforce Initiative reveal that there is a dedicated core of employees who remain

committed to direct support work and remain on the job for many years However, current conditions do not offer wage advancement or career opportunities that honor the service of these longer term employees Moreover, the continual traffic of inexperienced new hires thatleave within six months further strains the commitment of these dedicated staff

Along with stabilizing and improving the quality of the existing workforce, it will also be critical to find ways to attract new recruits into the field New pools of potential DSPs will need to be targeted, including recent immigrants, retirees, and others This suggests that it will be necessary to offer more literacy training to accommodate these employees and assure that organizations are culturally competent

The human service sector of the U.S economy will account for most job growth over the next decade, producing 3 of every 5 new jobs As baby boomers begin to age, and as

demand for care increases, developmental disabilities employers will be in intense

competition with other health and human service sector employers for entry and mid level employees as well as with non-service sector employers Furthermore, the total number of individuals with developmental disabilities in the United States in need of residential, in-home and day supports (excluding special education), is expected to rise from an estimated 977,000 in 2003 to 1,350,000 persons in 2020, an increase of about 37% percent (Lakin, Hewitt & Larson, 2005) This projection is based on current service patterns in the U.S., and assumes that the current trends toward deinstitutionalization of both State Operated

Developmental Centers (SODCs) and nursing homes will continue at the current rate and that current waiting lists will be eliminated (See Appendix B for more detail) Illinois will likelyencounter similar growth in the demand for supports and the need for DSPs to provide thosesupports

In fiscal year 2004, the Illinois Department of Human Services funded 413 organizations that provided community-based supports to people with developmental disabilities (Chmura

& Pettersson, 2005) Based on the number of people with developmental disabilities who receive supports funded by the Illinois Department of Human Services, we can estimate that those community developmental disabilities providers employed at least 28,167 full-time equivalent DSPs in 2004 (See Table 2) The actual number of people in DSP roles is probably higher than this because many DSPs work part-time and this estimate is based on full-time equivalents This estimate is also approximate because staff ratios for community settings inIllinois were not available at the time of this report Nevertheless, if Illinois experiences a 37% increase in the need for DSPs by 2020, an estimated additional 10,422 new FTE DSP positions will need to be filled (almost 700 new FTE positions per year) In addition, Illinois will have to replace the estimated 10,224 DSPs who will leave their positions each year

between now and 2020 and will have to fill the estimated 1,265 full-time equivalent DSP positions that were unfilled as of June 2004

The demand to fill newly created jobs will place enormous stress on community agencies that already have difficulty filling vacancies

Effect of turnover challenges

There are significant social and fiscal costs associated with turnover of DSPs The estimated cost to replace a DSP ranges from $2,000 to $5,000 per person (Fullager, 1998; Johnston, 1998; McDonald, 1994) At a cost of $3,500 per hire, the annual cost to Illinois (assuming 28,167 DSPs employed and a statewide turnover rate of 36.3%) would be $35.7 million per year just to replace current DSPs who leave their positions because so much money has to

be spent to get new hires trained and ready to work as well as covering their replacements who are working while the new hires are being trained It is important to figure out strategies

in Illinois to reduce the need to be replacing employees by being able to keep the ones that are hired

The fiscal costs, however, pale in comparison to the emotional toll and the impact on quality of life for the people who need daily support A study in Montana found that

“turnover was a significant predictor of increased limitation associated with secondary conditions; of more injury-related secondary conditions; of higher rates of health care

utilization; and of higher Medicaid costs” (Traci, Szalda-Petree, & Seninger, 1999) In

Minnesota, a study of Home and Community Based Services found that organizations with higher turnover rates experienced poorer outcomes for the people supported in the areas of health, access to desired community placements and self-determination (Larson, Hewitt, & Lakin, 2004)

Status of Education and Training

Most employers in Illinois and throughout the country do not require DSPs to have college degrees Job preparation for DSPs is typically accomplished through orientation and initial training as well as ongoing in-service training delivered by the employer The content of this training varies throughout the country depending upon the state regulations applicable to the program, the nature of the support provided, and the resources of the agency providing the training Most employer-based training meets minimal regulatory requirements with substantial portions focused on regulatory procedures, rather than the person-centered knowledge and skills identified as key professional competencies that lead to positive

outcomes

Many agency trainers are not well-versed in instructional design methods and effective adult learning methods, and the training does not culminate in a certificate, diploma, or other educational awards or recognition These patterns result in training that does little to

enhance employee motivation and commitment, or to create a pattern of linked steps

increasing professional knowledge and leading to career advancement Often it is repetitive, reactive, poorly planned, and structured to meet minimal standards rather than benchmarks

of excellence Employees do not view such training as an investment in their career, or their future in the field of developmental disabilities Hence, it does not work well in attracting or retaining employees

In 1999, the Illinois Department of Human Services established mandatory entry-level training for DSPs This training includes classroom instruction and on the job skill

demonstration and draws upon updated methods including the involvement of families and consumers in teaching activities While this training provides a solid introductory foundation for the DSP, more must be done to increase DSP levels of mastery and ethical practice to build a professional identity and increase expertise It will be critical to create high-quality certificate and degree and career development programs to provide DSPs with the

professional foundation for career commitment and achievement Henry (1994)

demonstrated the important connection between training preparation and quality outcomes within human services environments, as well as the positive impact of a comprehensive, well-organized training certificate program on employee retention and wages This evidence supports the common sense notion that employers who offer staff comprehensive

development programs including mentoring, skills certificates, engaging content and career opportunities are more likely to recruit and retain career oriented people who want to make

a commitment to the developmental disabilities field over the long run

Efforts to achieve the vision of an educated workforce must consider the likely barriers Many DSPs work more than one job so they can pay their bills This makes it difficult for them to participate in professional development opportunities outside of their scheduled work hours While employers do offer the required introductory training to their new

employees, few offer this training in the evenings and on weekends This prohibits many potential part-time employees from taking jobs because they are not able to or are unwilling

to use vacation time from their primary job to take the mandatory training for their part timejob Also, many work shifts are at times when training is not offered Options are needed to make learning more accessible to people who fit this profile On the employer side, rates need to be sufficient to assure that high-quality employee development programs do not cause shortages in other areas Any efforts to address training and development must take such factors into consideration

In the effort to improve educational opportunities, the stakeholders identified several important guidelines —

• Self-advocates and families should be involved as teachers in training and education programs for DSPs;

• Career and wage advancement criteria must be expanded to include educational progress and merit — not exclusively how long someone is employed;

• High-quality distance learning opportunities, such as the College of Direct Support, would improve access to essential knowledge;

• Professional expertise, commitment and identity will be strengthened by the creation of comprehensive and articulated educational and training programs

Making wiser use of existing funds and securing additional funding for recruitment and training of DSPs will improve outcomes, foster a more satisfied workforce, and provide greater career incentives for job seekers to choose a career in human services

Status of Wages and Benefits

Wages and benefits are an essential part of direct support work conditions While wage is notthe only factor affecting commitment to stay on the job, it is an important consideration in the decision whether to stay or move on to other jobs and careers Research has consistentlyshown that higher turnover is associated with low wages for DSPs (e.g., Braddock & Mitchell,1992; Lakin & Bruininks, 1981; Larson, Hewitt, & Lakin, 2004; Larson & Lakin, 1999; Larson, Lakin, & Bruininks, 1998; State of Minnesota, Department of Employee Relations, 1989) In organizations where DSPs have lower wages, the organizations typically experience higher turnover rates Lower DSP wages were also associated with poorer quality of life outcomes

as reported by family members and case managers (Larson, Hewitt, & Lakin, 2004)

Nationally, DSP wages have been so low that an estimated 20% of the direct support

workforce lives below the poverty line2 (Ebenstein & Gooler, 1994)

Three recent studies examined wages for DSPs in Illinois (See Table 3) Because of

variations in how positions were classified, a range of estimates for average DSP wages wereproduced For residential settings, the estimated average DSP wage ranged from $9.51 to

$10.16 For vocational settings, the average DSP wage ranged from $9.20 to $10.89 Two studies reported average wages for personal care attendants in in-home or respite settings (yielding estimates of $8.82 and $8.83) Average wages for house managers or supervisors ranged from $12.53 to $14.03 depending on the study and type of setting

Table 3 2005 Wages for DSPs in Illinois

Powers et al Chumura et al IARF

2 This assumes that the DSP is the only wage earner in a household size of 4 people Also, it assumes the DSP works a total of 40 hours per week in one or more DSP positions at the average wage, but does not have any additional jobs

Release Date March 31, 2005 June 30, 2005 April, 2005

N of Organizations 40%* 83 (for wage data) 49

Residential

Job Titles Used Direct Support

Providers

Habilitation Aide/ Worker

Residential Shift StaffMean Wage $10.16 CILA

Vocational or Rehabilitation Counselor

Developmental TrainingWorkshop Staff

Community Employment Behavior TechnicianDay Program Staff

*The preliminary report was based on a sample of 40% of IL providers According to Chumura et al

(2005), approximately 449 organizations provide community services to people with DD in Illinois.

Wage and benefit information is also available for the 18 organizations participating in thisproject (See Table 4) In 2004, project participants paid DSPs in vocational, residential, in-

home and child care settings an average of $10.12 per hour The average DSP starting wage

in those organizations was $9.00 and the average highest wage was $14.56 These

estimates are in the middle of the range reported in other studies The average wage for FLSs in participating organizations was $14.80 This was higher than reported in the other studies, possibly because some people in QMRP positions (degreed professionals who

develop and monitor programs designed to teach new skills) paid at a higher rate, were included as supervisors

Table 4 2004 Wages and Benefits for Participating Organizations

Characteristic

2004 Project Participants

Percent of DSPs considered to be full-time 72%

Average number of hours required to be considered 35

Number of hours worked to be eligible for benefits 33.4

Number of hours worked to be eligible for paid time off 23.1

In 13 of the 17 reporting organizations participating in this project, only full-time

employees are eligible for health care coverage In the other four organizations, employees who worked 30 hours a week or more were eligible

Two recent studies provide more information about benefits for staff of community based programs (IARF, 2005; Powers, Powers, & Merriman, 2005) While 90% to 94% of community organizations supporting individuals with developmental disabilities offer access to health care benefits to at least some employees, only 52% of employees in those organizations receive health care benefits (Powers, Powers & Merriman, 2005) Employer costs for fringe benefits (health care and retirement) ranged from 8% to 10% of total compensation across all employees

The IARF (2005) study provides information that helps explain some of the findings in the Powers et al (2005) study For example, in the IARF study, employers reported that to be eligible for benefits, an employee had to work an average of 37.2 hours per week While

69% of employers used part-time employees, only 53% of the providers offered pro-rated benefits for part time employees In those organizations, part-time DSPs had to work an average of 19.85 hours per week to be eligible for benefits For employees who are eligible for health insurance benefits, employers covered an average of 83% of the cost for

employee only coverage, and 65% of the costs for family (dependent and spouse) coverage

Of employers offering health insurance, 41% reported that they did not pay any of the cost

of family coverage

As these studies show, many DSPs in community settings, especially those who worked part-time, were not eligible for health care benefits Even when benefits are available, many DSPs cannot afford to purchase them for their families For example, a DSP earning $10 per hour ($400 per week, less FICA and Social Security) is hard pressed to afford the typical monthly family health care premium of $300 This lack of access to affordable health care foremployed DSPs is an important factor influencing recruitment and retention success

It is also important to note that many DSPs qualify for programs that are designed to support people with low to moderate incomes such as food stamps, affordable housing programs, and the earned income tax credit or child care credit

Effect of Current Conditions

At issue here is not simply a better functioning workforce; the lives of people with disabilitieswho receive services and supports are shaped by the nature of the supports they receive When DSPs do not really know the people for whom they provide supports and services, theycannot offer individualized supports When the direct support workforce is poorly trained, service recipients do not develop essential skills There is an emotional toll as well — servicerecipients and families are afraid that the support they need will not be there for them, and they experience increased frustration They cannot depend on the people in their lives for support because those people are constantly changing

Current conditions force us to ask —

• What can we do to provide a foundation for adequate, effective, and ethical support for individuals with developmental disabilities in Illinois?

• What can we do to enrich and expand the number of DSPs available to support people with developmental disabilities in the state?

• What can we do to ensure that DSPs are trained and supported to help peoples with developmental disabilities be safe, healthy, and to reach their life goals and dreams? This report offers recommendations addressing these questions

Action Plan: The Illinois Quality Support Agenda 2005

The vision and interventions discussed in this plan provide a framework to address

challenges in recruitment and retention of DSPs The following goals were developed by the Steering and Advisory Committee to build a stronger DSP workforce

Recruitment and Retention Strategies

Attract and Retain Qualified DSPs

Goal 1: Conduct annual an on-going legislative advocacy campaigns to increase the

wages and benefits of DSPs and FLSs by not less than $3.00 per hour by December, 2008

Goal 2: Disseminate and implement a public relations campaign kit throughout the

state by December, 2007

Goal 3: Improve the knowledge of supervisors related to recruitment and retention

strategies by December, 2006

Education, Training and Career Development

Raise the Skill and Knowledge of DSPs

Goal 1: Building on existing DHS competencies for DSPs, develop intermediate and

advanced education opportunities that bear college credit and that lead to voluntary, specialized credentialing by May 2007

Workforce Data and Statistics

Develop a Systemic Strategy to Monitor DSP Wages, Benefits, and Workforce Outcomes

Goal 1: Convene stakeholders to identify statewide data needed regarding the

community services DSP workforce supporting individuals with developmental

disabilities in Illinois, inventory existing and potential sources of that data, and make recommendations about ongoing data collection, evaluation, and reporting strategies

by June, 2007

Goal 2: Report annually on the extent to which an adequate supply of DSPs is available

to provide community based supports and services for citizens with developmental disabilities by June, 2007